Radical cystectomy in octogenarian patients: a difficult decision to take.

INTRODUCTION: The increasing life expectancy and the proportion of octogenarians make radical cystectomy (RC) more frequent in octogenarian patients with muscle invasive bladder cancer. OBJECTIVE: To analyze overall survival and complications in our series. MATERIAL AND METHODS: Descriptive analysis of patients older than 80 years undergoing RC between 2000 and 2012. Surgical risk (American Society of Anesthesiologists scale, ASA), hospital stay, complications (Clavien-Dindo classification) and types of urinary diversion were evaluated. Variables were expressed in mean or medians. Overall survival was analyzed using the Kaplan-Meier method. Univariate overall survival analysis was performed using the univariate Cox regression model. The null hypothesis was rejected by a type I error <0.05. Statistical analyses were performed using SPSS 15.0 (SPSS Inc., Chicago, Ill., USA). RESULTS: Thirty-three patients were included. Their mean age was 81.9 ± 1.8 years. There were 24 males (72.7%). The surgical risk was identified as follows: ASA II in 9 patients (27.3%), ASA III in 23 (69.7%) and ASA IV in 1 (3%). Concerning urinary diversion, 19 patients (57.6%) underwent ureteroileostomy and 14 (42.4%) bilateral cutaneous ureterostomy. Average hospital length of stay was 19 days (14-30). TNM stage was T0 in 1 patient (3%), T1 in 4 (12.1%), T2 in 11 (33.3%), T3 in 13 (39.4%), T4 in 4 (12.1%), Nx in 9 (12%), N0 in 13 (39.4%), N1 in 3 (9.1%), and N2 in 5 (15.2%). The most frequent complications were pneumonia in 6 patients (18.2%) and surgical wound infection in 6 (18.2%). Lymphadenectomy did not involve a significant increase in complications. Six patients (18.2%) died in the immediate postoperative period, 5 of whom from respiratory complications. The mean survival of the rest of the series was 24 months (range 15.1-32.8). CONCLUSIONS: Overall assessment of the patient is essential and not only the chronological age. RC is a valid option despite chronological age. In the postoperative period, there is a higher risk of complications but not higher mortality due to surgical complications.

Pyeloureteral Anastomosis as a Reconstructive Technique for Post-Renal Transplant Ureteral Stenosis.

OBJECTIVE: Ureteral stenosis in renal transplant patients is a frequent urological complication that involves significant morbidity and may compromise graft function. Despite the common use of minimally invasive techniques, surgery continues to be the definitive treatment for ureteral stenosis, and pyeloureteral anastomosis is an infrequent but effective technique in the management of this pathology and has been described as a safe treatment with a low percentage of complications. METHODS: This is a retrospective study of patients in whom surgical intervention via pyeloureteral anastomosis was carried out in our center in the last 12 years. A descriptive analysis of perioperative management, complications, and functional results is provided. A comparison of renal function at diagnosis and after surgery was made to evaluate the effectiveness of the procedure. RESULTS: Thirteen patients underwent surgery within the described time frame. Time to diagnosis of stenosis was 60 days [interquartile range (IQR) 31-368]. Creatinine at diagnosis was 2.2 mg/dL [IQR 1.9-3] with a glomerular filtration rate, estimated by the modification of diet in renal disease equation, of 29 mL/min/1.73 m2 [IQR 22.6-34.5]. Of these patients, 92.3% underwent percutaneous nephrostomy, and 38.5% also had a ureteral catheter. The mean duration of surgery was 265 minutes [IQR 240-300], and hospital stay was 9 days [IQR 7.5-16]. A double J was placed in all cases, which was maintained for 36 days [IQR 30-49]. Postoperative complications occurred in 15.4% of patients. Serum creatinine 1 year after surgery was 1.6 ± 0.4 mg/dL. Among the patients, 76.9% had no new pyelocalyceal dilatation on follow-up Doppler ultrasound scans at a mean follow-up time of 12 months. The restenosis rate was 23.1%, and all were successfully treated by endoscopic approach. There was an improvement in renal function figures at 1, 3, 6, and 12 months compared to renal function at diagnosis, both in terms of serum creatinine and glomerular filtration rate, with statistically significant results. CONCLUSION: Pyeloureteral anastomosis as a reconstructive technique of the urinary tract in renal transplant patients is an effective and reproducible technique with good long-term results.

[Laparoscopic renal cyst excision: Large simple renal cyst treatment with renal cell carcinoma cells in its wall. Histogenetic considerations and bibliographic review.] / Quistectomía laparoscópica: tratamiento de un quiste simple de gran tamaño con carcinoma de células renales en su pared. Consideraciones histogenéticas y revisión de la literatura.

OBJECTIVE: The incidence of simple renal cysts is very high, especially in elderly people. However, malignant transformation of a simple renal cyst is exceptional. Likewise, the treatment to be carried out, in these rare cases, is controversial, with respect to opting for radical renal surgery. METHODS: We present the case of a patient with a solid nodule in a large cyst. Complete removal of the cyst was performed by transperitoneal laparoscopic technique. The histopathological study of the surgical piece revealed the existence of a cyst with clear renal cell carcinoma with nucleolar grade 2. The clinical evolution has been satisfactory, performing a minimally invasive surgery (laparoscopic cyst excision). DISCUSSION: Although it is considered that surgical treatment of choice is radical surgery in these cases, we believe that nephron sparing surgery may represent a therapeutic option, taking into account the young age of our patient. A histogenetic hypothesis is discussed to explain the appearance of a clear cell tumor in a simple renal cyst. CONCLUSION: The development of a renal cell carcinoma in simple renal cysts is a very infrequent pathology.Laparoscopic total cystectomy is a minimally invasive therapeutic option for the treatment of renal cell carcinoma originating in a simple renal cyst, although it is of an important size. We establish the hypothesis of migration of the cells of the renal collecting tubes into the cyst wall to explain the malignant transformation of the renal simple cyst.

OBJETIVO: La incidencia de los quistes renales simples es muy frecuente, sobre todo en personas de edad avanzada. Sin embargo, la transformación maligna de un quiste renal simple es excepcional. Así mismo, el tratamiento a realizar, en estos casos raros, es un motivo de controversia, con respecto a optar por una cirugía radical renal.MÉTODOS: Presentamos el caso de un paciente con nódulo sólido en un quiste de gran tamaño. Se realiza extirpación completa del quiste mediante técnica de laparoscopia vía transperitoneal. El estudio histopatológico de la pieza quirúrgica revela la existencia un quiste con un carcinoma renal de células claras con grado nucleolar 2. La evolución clínica ha sido satisfactoria, realizando una cirugía de mínima invasión (quistectomía laparoscópica). DISCUSIÓN: Aunque se considera que el tratamiento quirúrgico es la cirugía radical en estos casos, nosotros consideramos que la cirugía preservadora de nefronas puede representar una opción terapéutica, teniendo en cuenta la edad de nuestro paciente. Se comenta una hipótesis histogenética para explicar la aparición de un tumor de células claras en un quiste renal simple. CONCLUSIONES: El desarrollo de un carcinoma de células renales en quistes renales simples es una patología muy infrecuente. La quistectomía total laparoscópica es una opción terapéutica mínimamente invasiva, para el tratamiento del carcinoma de células renales originado en un quiste renal simple, aunque éste sea de un tamaño importante. Proponemos la hipótesis de una migración de las células de los túbulos renales en la pared del quiste para explicar la transformación maligna del quiste simple renal.

Quistectomía laparoscópica: tratamiento de un quiste simple de gran tamaño con carcinoma de células renales en su pared. Consideraciones histogenéticas y revisión de la literatura / Laparoscopic renal cyst excision: Large simple renal cyst treatment with renal cell carcinoma cells in its wall. Histogenetic considerations and bibliographic review

Objetivo: La incidencia de los quistes renales simples es muy frecuente, sobre todo en personas de edad avanzada. Sin embargo, la transformación maligna de un quiste renal simple es excepcional. Así mismo, el tratamiento a realizar, en estos casos raros, es un motivo de controversia, con respecto a optar por una cirugía radical renal. Métodos: Presentamos el caso de un paciente con nódulo sólido en un quiste de gran tamaño. Se realiza extirpación completa del quiste mediante técnica de laparoscopia vía transperitoneal. El estudio histopatológico de la pieza quirúrgica revela la existencia un quiste con un carcinoma renal de células claras con grado nucleolar 2. La evolución clínica ha sido satisfactoria, realizando una cirugía de mínima invasión (quistectomía laparoscópica). Discusión: Aunque se considera que el tratamiento quirúrgico es la cirugía radical en estos casos, nosotros consideramos que la cirugía preservadora de nefronas puede representar una opción terapéutica, teniendo en cuenta la edad de nuestro paciente. Se comenta una hipótesis histogenética para explicar la aparición de un tumor de células claras en un quiste renal simple. Conclusiones: El desarrollo de un carcinoma de células renales en quistes renales simples es una patología muy infrecuente. La quistectomía total laparoscópica es una opción terapéutica mínimamente invasiva, para el tratamiento del carcinoma de células renales originado en un quiste renal simple, aunque éste sea de un tamaño importante. Proponemos la hipótesis de una migración de las células de los túbulos renales en la pared del quiste para explicar la transformación maligna del quiste simple renal

Objective: The incidence of simple renal cysts is very high, especially in elderly people. However, malignant transformation of a simple renal cyst is exceptional. Likewise, the treatment to be carried out, in these rare cases, is controversial, with respect to opting for radical renal surgery. Methods: We present the case of a patient with a solid nodule in a large cyst. Complete removal of the cyst was performed by transperitoneal laparoscopic technique. The histopathological study of the surgical piece revealed the existence of a cyst with clear renal cell carcinoma with nucleolar grade 2. The clinical evolution has been satisfactory, performing a minimally invasive surgery (laparoscopic cyst excision). Discussion: Although it is considered that surgical treatment of choice is radical surgery in these cases, we believe that nephron sparing surgery may represent a therapeutic option, taking into account the young age of our patient. A histogenetic hypothesis is discussed to explain the appearance of a clear cell tumor in a simple renal cyst. Conclusion: The development of a renal cell carcinoma in simple renal cysts is a very infrequent pathology Laparoscopic total cystectomy is a minimally invasive therapeutic option for the treatment of renal cell carcinoma originating in a simple renal cyst, although it is of an important size. We establish the hypothesis of migration of the cells of the renal collecting tubes into the cyst wall to explain the malignant transformation of the renal simple cyst